Prime Contractor Paid/unpaid Mbe Invoice Report Template Page 3
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1
2
3This form must be completed
monthly by all MBE subcontractors.
Sample MBE ATTACHMENT D-5
Minority Business Enterprise Participation
Subcontractor Paid/Unpaid MBE Invoice Report
Contract #
Report#: ____
Contracting Unit:
MBE Subcontract Amount:
Reporting Period (Month/Year): ________________
Project Begin Date:
Project End Date:
th
Report is due by the 10
of the month following the month
Services Provided:
the services were performed.
MBE Subcontractor Name:
MDOT Certification #:
Contact Person:
E-mail:
Address:
City:
State:
ZIP:
Phone:
Fax:
Subcontractor Services Provided:
List all payments received from Prime Contractor during
List dates and amounts of any unpaid invoices over 30
reporting period indicated above.
days old.
Invoice Amt
Date
Invoice Amt
Date
1.
1.
2.
2.
3.
3.
Total Dollars Paid: $_________________________
Total Dollars Unpaid: $_________________________
Prime Contractor:
Contact Person:
**Return one copy of this form to the following address (electronic copy with signature & date is
preferred):
___________________________Contract Monitor
____________________________Contracting Unit
(Department)
___________________________________
___________________________________
___________________________________
___________________________________
Signature:________________________________________________ Date:_____________________
(Required)
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